A focus on progestogens in HRT TOG 2023

Question 1

Purpose of progestogens in HRT

Answer 1

to reduce the risk of endometrialhyperplasia and endometrial cancer, which occurs withunopposed estrogen, unless they have had a hysterectomy.

Question 2

Explanation progestogens, progesterone, progestins

Answer 2

Question 3

In terms of timing, how can they be given

Answer 3

12-14 days per month, regular withdrawal bleed

Continous - avoid bleed

Question 4

Flow diagram explaining synthetic progestogens and relation to progesterone and testosterone

Answer 4

Question 5

Table showing different delivery of progesterones

Answer 5

Question 6

Which regime offers better endometrial protection continuous or sequential

Answer 6

Continous but higher incidence of unscheduled bleeding.

Question 7

Most common route of progesterone in HRT

Answer 7

Oral route

Micronised
- 200mg 12-14days per cycle
- 100mg continuous

Question 8

Which routes have fewer side effects

Answer 8

Bypass 1st metabolism in liver
Transdermal, vaginal or intra-uterine

IUS fewest SE, most likely to cause amenorrhea

Micronised few SE as more selective to PR, LNG-IUS and preparations with dydrogesterone few SE

Question 9

Which IUS licenceed for endometrial protection

Answer 9

Levonorgestrel IUS 52mg for 4 years

Question 10

Can progesterone cream be used?

Answer 10

No unreliable

Question 11

Most common SE of progesterones?

Answer 11

Mood disturbance & fluid retention

Micronised has fewer

Question 12

If severe effect on mood, what can advice?

Answer 12

Half the dose or reduce duration 7-10days but increased risk of endometrial hyperplasia

Question 13

How common is unscheduled bleeding on HRT at 9 months?

Answer 13

3-10%

Continous > Sequential

Transdermal more likely than oral

Question 14

If unscheduled bleeding after 4 months that can be offered?

Answer 14

Change the progesterone dose or route

Continous oral - increase from 100 to 200 or offer IUS

Sequential oral - increase 200 to 300 or increased duration 14-21 days

If IUS can offer supplementary progesterone MPA/NET

Question 15

If further unsechudeld bleeding despite changing progesterone?

Answer 15

TVUS USS

• For continuous - use 4mm cut off
• For sequential - use 7mm cut off

Question 16

Table showing RF of breast cancer

Answer 16

Combined worse than unopposed
Combined similar to risk of obesity and alcohol
Less risk with micronised progesterone and dydrogesterone

Question 17

Cardiovascular risk and HRT

Answer 17

Estrogen only HRT < 60 years to within 10 year menopause, reduced CV risk
Estrogen alone better effect than with progesterone

Question 18

Risk of HRT & stroke

Answer 18

Higher with oral preparations

Higher risk - transdermal safest option

Question 19

Increased risk of VTE on HRT?

Answer 19

2-4 times, 1st year greatest risk

Micronised progesterone and dydrogesterone lowest risk

Oral HRT with MPA - highest risk

Transfermal not elevated risk